DOI: 10.14260/jemds/2015/80
ORIGINAL ARTICLE
COMPARISON OF THE EFFECTS OF LIGNOCAINE, LIGNOCAINE PLUS
PARACETAMOL, LIGNOCAINE PLUS TRAMADOL IN INTRAVENOUS
REGIONAL ANESTHESIA
Amar Parkash Kataria1, Mandip Kaur2, Anju Bala3, Harcharan Singh4, Jugal Kumar5, Radhe Sharan6
HOW TO CITE THIS ARTICLE:
Amar Parkash Kataria, Mandip Kaur, Anju Bala, Harcharan Singh, Jugal Kumar, Radhe Sharan. “Comparison of
the Effects of Lignocaine, Lignocaine plus Paracetamol, Lignocaine Plus Tramadol in Intravenous Regional
Anesthesia”. Journal of Evolution of Medical and Dental Sciences 2015; Vol. 4, Issue 04 January 12;
Page: 539-544, DOI: 10.14260/jemds/2015/80
ABSTRACT: INTRODUCTION: Intravenous regional anesthesia is simple, effective technique for
upper limb orthopedic surgeries however adjuncts are required to improve its efficacy. AIMS: To
compare the effects of adding paracetamol and tramadol as adjunct to lignocaine in intravenous
regional anesthesia on onset and regression of sensory and motor blockage, analgesic requirements,
duration of analgesia and side effects. PATIENTS AND METHOD: A randomized study was carried
out on ninety patients who were undergoing upper limb orthopedic surgery, divided in to three
groups: group I (L) received 3mg/kg lignocaine 0.5% diluted up to 40 ml with normal saline, group II
(LP) received 3mg/kg lignocaine 0.5% with 300mg paracetamol diluted up to 40 ml with normal
saline, group III (LT) received 3mg/kg lignocaine 0.5% with tramadol 100mg diluted up to 40 ml with
normal saline. Sensory and motor block onset, regression time, intraoperatively and postoperatively
VAS score, duration of analgesia, total analgesic consumption in first 24 hr and side effects noted.
Analysis of data based on chi square test and post hoc test. P value < 0.05 considered significant.
RESULTS: A total of ninety patients were included in study. The mean age of patients in group I was
32.60±14.8 years, in group II was41.67±16.6 years while in group III was 38.73±13.3 years. Tramadol
with lignocaine was found to be significantly better as compared to paracetamol and lignocaine alone
had early onset and delayed offset of sensory and motor block. The tramadol group required
significantly less number of rescue analgesics in first 24 hours as compared to the other two groups.
CONCLUSION: We concluded that as adjuvant tramadol group was accompanied by more rapid onset,
longer duration of analgesia provides better quality of anesthesia and lesser number of patients
require rescue analgesia intraoperatively as well as postoperatively without any significant side
effects.
KEYWORDS: Intravenous regional anesthesia, Tramadol, Paracetamol, Postoperative Pain.
INTRODUCTION: IVRA was first described by August Bier in 1908 for short operative procedures on
upper arm surgeries.[1] It became popular in 1960s when lidocaine was used.[2] It is simple to
administer, cost effective, reliable[3] and has minimal interference with the normal metabolic
processes of the body. It lacks the complications associated with the general anesthesia. Limitations
of IVRA include slow onset, local anesthetic toxicity, poor muscle relaxation, tourniquet pain, minimal
post-operative analgesia.[4] To remove these limitations various adjuvants has been added like
fentanyl, tramadol, clonidine, dexamethasone, NSAIDS like ketorolac,[5] acetyl-salicylate, and muscle
relaxants.[6]
Tramadol[7] acts at the µ-opioid receptors, releases serotonin and in addition it interferes with
neurotransmitter reuptake. Paracetamol[8] inhibits prostaglandin synthesis and by modulating
cannabinoid receptors exhibits local antinociceptive effects.
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ORIGINAL ARTICLE
The study have been done to compare and evaluate tramadol or paracetamol to lignocaine in
IVRA, on onset, regression time for sensory and motor block, intra-operative as well as postoperative analgesia.
MATERIAL AND METHODS: After approval of the ethical committee, a prospective, randomized
double blind study done on 90 patients of age 18-65 years of ASA grade I, II, III were divided in to
three groups randomly of 30 each after taking written informed consent. Lignocaine used was
preservative free.
Group I (L): 3 mg/kg lignocaine 0.5% diluted up to 40 ml with normal saline.
Group II (LP): 3 mg/kg lignocaine 0.5% with 300 mg paracetamol diluted up to 40 ml with normal
saline.
Group III (LT): 3 mg/kg lignocaine 0.5% with 100 mg tramadol diluted up to 40 ml with normal
saline.
After confirming fasting, pre-operative investigations, pre- anesthetic check-up patients were
taken up for surgery. Patients with coagulation disorders like sickle cell disease, Raynaud’s disease
and history of any drug allergy were excluded from the study. A randomization list was generated
and identical syringes containing each drug were prepared by personnel blinded to study. No
premedication as analgesics, sedatives or antisialogogues was given before operation.
After assessing baseline vitals as noninvasive blood pressure, ECG, pulse rate, peripheral
oxygen saturation, one cannula was inserted on operative hand and other on the opposite hand for
injection of drugs and crystalloid infusion. The operative arm was exsanguinated with esmarch
bandage. After applying pneumatic”double” tourniquet the proximal cuff was inflated to 250 mm Hg.
Before injecting local anesthetic by inspection, by absence of radial pulse, circulatory isolation of arm
was confirmed. Then patients were injected with one of the study drug.
After injection sensory block was assessed in sensory distribution of median, ulnar, radial
nerves of hand by pinprick method. Motor function was assessed by flexion and extension of wrist
and fingers of the patients. After achieving sensory and motor block the distal tourniquet was inflated
to 250 mm Hg then proximal tourniquet was deflated, and operation was started.
After tourniquet application tourniquet pain was assessed at 10 min intervals by visual
analogue scale (0 = no pain and 10 = worst pain). If VAS >3 inj butorphanol 0.5 mg was given and
requirement for rescue analgesic doses was recorded.
The tourniquet was neither deflated before 30 min nor inflated more than 90 min of local
anesthetic injection. After the completion of surgery, the tourniquet deflation was done by cyclic
deflation technique. Sensory and motor block recovery time was noted.
Postoperatively VAS score was measured for surgical pain every hourly after tourniquet
deflation until 4 hours than 4 hourly till 12 hours and at 24 hours. Rescue analgesia in terms of inj
diclofenac 75 mg IM was given if VAS > 3. Total number of rescue analgesic required in first
24 hours were recorded. Intraopertatively as well as postoperatively any local or systemic
complications noted.
Statistical analysis was performed with SPSS 17.0 version. Statistical analysis for comparisons
with ‘chi-square’ test and ‘ post-hoc’ test was done. P value of <0.05 assumed significant. Based on
duration of analgesia power of study was > 90%.
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RESULTS: All the groups were comparable with regard to age, sex, weight, ASA, duration of surgery.
There was no significant difference among groups when compared for MAP, pulse rate, oxygen
saturation, sedation score intraoperatively as well as post-operatively.
The onset of sensory and motor block was significantly lower in group LT and group LP than
group L (<0.001). The recovery of sensory as well as motor block was delayed in group LT and group
LP than group L (<0.001). There was significant difference among group LP and group LT when
compared for onset as well as offset of sensory and motor block.
Intraoperatively VAS score was high in lignocaine group at 20 min, 30 min, 40 min, 50 min.
Intraoperatively the total number of doses of rescue analgesic was significantly more in group L than
group LP and group LT respectively. Postoperatively VAS score was significantly lower at 30 min, 1
hour, 2 hours, in LT group than group LP and group L. The total number of inj diclofenac use was less
in group LT and group LP than group L. Total duration of analgesia was significantly higher in group
LT than group LP and group L. There were no significant side effects seen in three groups.
DISCUSSION: Surgical trauma causes mechanical damage to nerve endings which results in
postoperative pain. Due to inflammation release of endogenous chemical mediators occur which
cause activation of nociceptors. If these nociceptive pathways blocked prior to surgical stimuli, the
changes will be diminished or prevented. IVRA, a venous technique where anesthetics acts at the
peripheral nerve endings and anaesthetizes the major nerve trunks, therefore it could be described
as “peripheral nerve block”. NSAIDS, in addition to lignocaine minimizes the activation of peripheral
nociceptors.
The current study concluded that addition of either tramadol or paracetamol to lidocaine in
IVRA lead to early onset as well as delayed offset of sensory and motor block. In Yasser M et al
study[9] using 100 mg tramadol with 3 mg/kg 0.5% lidocaine in IVRA showed significantly early onset
time and delayed recovery time of sensory and motor block than lignocaine group. In Sen et al[10]
study on addition of paracetamol to lignocaine 3 mg/kg in IVRA lead to early onset of motor block
and delayed offset of sensory and motor block than lignocaine group. Our results were in accordance
with results of these studies.
In present study in tramadol group and paracetamol group the requirement of rescue
analgesic was less intraoperatively and postoperatively than lignocaine group. Tramadol group has
lower VAS score than paracetamol and lignocaine group postoperatively. Chakole V et al[11] conducted
a study with lignocaine 0.5% and tramadol 100 mg demonstrated that postoperatively consumption
of rescue analgesic doses was significantly lower in tramadol group than lignocaine group. Ko MJ et
al[12] study concluded that addition of acetaminophen to lidocaine for IVRA reduces postoperative
analgesic consumption. The results were in accordance with our study.
Duration of analgesia was significantly higher in tramadol group than paracetamol and
lignocaine group. Dubey et al[13] showed on addition of lidocaine to tramadol result in prolonged
duration of analgesia. Goel et al[14] also demonstrated tramadol in addition to lidocaine result in
significantly longer pain free interval than lignocaine group. The results were in accordance with our
study.
CONCLUSION: Addition of tramadol 100 mg or paracetamol 300 mg to lignocaine 3 mg/kg 0.5%
shortens the onset time of sensory and motor block, prolongs the recovery of sensory and motor
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ORIGINAL ARTICLE
block. However, tramadol group was accompanied by more rapid onset, longer duration of analgesia
provides better quality of anaesthesia and lesser no. of patients require rescue analgesia intraoperatively as well as post-operatively.
Age (yr)
Group I
Group II
Group III
P value
(L)
(LP)
(LT)
32.60±14.8 41.67±16.6 38.73±13.3
0.62
Sex (M:F)
23:7
20:10
23:7
0.60
Weight (kg)
ASA
(Mean ± SD)
Duration of surgery
(min)
67.0±5.6
68.87±4.9
68.80±5.1
0.3
1.57±0.67
1.60±0.62
1.63±0.61
0.92
41.63±7.2
40.57±7.8
40.57±7.9
0.82
Table 1: Demographic Data
p> 0.05; NS.
Group I
(L)
Sensory block onset(min)
Sensory block recovery(min)
Motor block onset(min)
Motor block
recovery(min)
Intraoperative
analgesic consumption
(Mean±SD)
Postoperative analgesic
Consumption
(Mean±SD)
Duration of postoperative analgesia
(in hr)
GroupIII
(LT)
p value
4.88±0.46 4.35±0.43 2.25±0.43
4.93±0.52
7.1±0.80 7.80±0.61
11.28±0.48 7.2±0.59 4.76±0.48
0.000*
0.000*
0.000*
4.91±0.45
7.1±0.59
9.56±0.72
0.000*
0.47±0.62
0.1±0.34
0.07±0.25
0.001*
3.20±0.40
2.2±0.4
1.60±0.49
0.001*
1.43±0.56
GroupII
(LP)
1.90±0.60 8.00±2.77
0.000*
Table 2: Sensory and Motor Block onset and recovery time.
p> 0.05; NS: *p< 0.05;S; p<0.001;HS
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Time
Group I
(L)
Mean±SD
Group II
(LP)
Mean±SD
Group III
(LT)
Mean±SD
p value
20 min
30 min
40 min
50 min
0.97±0.96
2.07±0.58
2.78±0.69
3.20±0.67
0.27±0.45* 0.2±0.45*
1.47±0.93* 1.33±0.66*
1.79±0.72* 1.75±0.67*
2.44±0.72* 2.38±0.71*
0.000*
0.01*
0.000*
0.004*
Table 3: Intraoperative VAS score
p> 0.05; NS: *p< 0.05; S;* p<0.001; HS.
Group I
Group II Group III
p
Time
(L)
(LP)
(LT)
value
Mean±SD Mean±SD Mean±SD
30 min 1.63±0.49 0.43±0.72*
0
0.000*
*
*
1 hr
3.53±0.6 1.73±1.43 1.13±0.7 0.000*
2 hrs 3.33±0.54 3.27±1.0* 2.10±0.4* 0.000*
3 hrs 2.37±0.85 2.43±0.72 2.27±0.45 0.64
4 hrs 2.67±0.60 2.67±0.54 2.77±0.93 0.82
8 hrs 3.63±0.71 3.40±0.85 3.03±1.1* 0.04*
12 hrs 3.13±0.86 3.13±0.97 3.03±0.9
0.89
24hrs 3.20±0.66 2.97±0.32 2.9±0.18
0.06
Table 4: Postoperative VAS score
p> 0.05; NS: *p< 0.05; S;* p<0.001;HS
REFERENCES:
1. Dos Reis A Jr. Intravenous regional anesthesia-first century. Beginning, development, and
current status. Rev Bras Anestesiol. 2008; 58 (3): 299-321.
2. Van Zundert A, Helmstadter A, Goerig M, Mortier E. Centennial of intravenous regional
anesthesia. Bier’s Block. Reg Anesth Pain Med. 2008; 33 (5): 483-9.
3. Mohr B Safety and effectiveness of intravenous regional anesthesia (Bier block) for outpatient
management of forearm trauma. CJEM. 2006; 8 (4): 247-50.
4. Vlassakov KV, Bhavani K. The forearm tourniquet Bier block. Logic and authority versus science
and experience. Minerva Anestesiol. 2010; 76 (2): 91-2.
5. Reuben SS, Steinberg RB. Intravenous regional anaesthesia using lignocaine and ketorolac.
Anesth Analg. 1995; 81: 110-13.
6. Elhakim M, Sadek RA. Addition of atracurium to lidocaine for IVRA. Acta Anaesth Scand. 1994;
38: 54-8.
7. Stoelting, Robert K., Pharmacology and physiology in anesthetic practice, Philadelphia:
Lippincott-Raven publishers., 1999. 814p.
8. Grahm GG, Scott KF. Mechanism of action of paracetamol. Am J Ther 2005; 12: 46-55.
J of Evolution of Med and Dent Sci/ eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 4/ Issue 04/Jan 12, 2015
Page 543
DOI: 10.14260/jemds/2015/80
ORIGINAL ARTICLE
9. Nasser M Yasser, Waly H Salwa Iidocaine-tramadol versus lidocaine-dexmedetomidine for
intravenous regional anesthesia. Egyptian Journal of Anaesthesia. January 2012, Vol. 28 (1): 3742, doi: 10.1016.
10. Sen H, Kulachi Y, Bicerer E, Ozkan S, Dagli G, Turan A. The Analgesic Effect of paracetamol when
Added to Lidocaine for Intravenous Regional Anesthesia. Anesth Analg. 2009; 109 (4): 1327-30.
11. Chakole V, Dixit R, Tadwalker G –Effect of tramadol on Post-operative analgesia when added to
lidocaine in intravenous regional anesthesia (bier’s block) for upper arm orthopaedic surgeries.
2012-jemds.com.
12. Ko MJ, Lee JH, Cheong SH, Shin CM, Kim YJ, Choe YK, et al Comparison of the effects of
acetaminophen to ketorolac when added to lidocaine for intravenous regional anesthesia.
Korean j Anesthesiol. 2010A; 58 (4): 357-361.
13. Dubey K, Paddalwar S, Chandak A. A comparative double blind study of tramadol and fentanyl
as adjuvants to lignocaine for intravenous regional anesthesia for forearm orthopaedic
surgeries. Indian J Pain: 29.
14. Goel Sunita N, Daftary Swati R, Pantavaidya Shanti H. Intravenous regional anaesthesia using
tramadol hydrochloride and ketorolac: a double blind controlled study: Indian J. Anaesth. 2002;
46 (5): 369-372.
AUTHORS:
1. Amar Parkash Kataria
2. Mandip Kaur
3. Anju Bala
4. Harcharan Singh
5. Jugal Kumar
6. Radhe Sharan
PARTICULARS OF CONTRIBUTORS:
1. Professor, Department of Anaesthesiology
& Intensive Care Unit, Government
Medical College, Amritsar.
2. Junior Resident, Department of
Anaesthesiology & Intensive Care Unit,
Government Medical College, Amritsar.
3. Senior Resident, Department of
Anaesthesiology & Intensive Care Unit,
Government Medical College, Amritsar.
4. Associate Professor, Department of
Anaesthesiology & Intensive Care Unit,
Government Medical College, Amritsar.
5.
6.
Senior Resident, Department of
Anaesthesiology & Intensive Care Unit,
Government Medical College, Amritsar.
Associate Professor, Department of
Anaesthesiology & Intensive Care Unit,
Government Medical College, Amritsar.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Mandip Kaur,
Vill. Daulatpura,
P. O. Jhanduke,
Bathinda, Punjab.
E-mail: [email protected]
Date of Submission: 22/12/2014.
Date of Peer Review: 23/12/2014.
Date of Acceptance: 02/01/2015.
Date of Publishing: 09/01/2015.
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